NURS FPX 6212 Assessment 4 Planning for Change: A Leader’s Vision
Student Name Capella University NURS-FPX 6212 Health Care Quality and Safety Management Prof. Name Date Planning for Change: A Leader’s Vision Medication errors (MEs) remain a critical safety concern at Mercy General Hospital (MGH), directly influencing patient outcomes, care quality, and operational effectiveness. A structured and evidence-informed transformation plan is necessary to redesign workflows, strengthen clinical practices, and leverage health technologies. Reducing MEs is not only a clinical priority but also a strategic imperative to enhance patient safety culture and sustain quality improvement. Achieving this vision requires coordinated leadership, targeted workforce development, and the integration of advanced medication management systems that support safe and accurate drug administration. Presentation Objectives This initiative is guided by clearly defined objectives that align with patient safety and quality improvement priorities. These objectives address both systemic gaps and measurable outcomes. Metric Purpose Evaluation Timing Medication error frequency Tracks safety performance Pre- and post-implementation Patient satisfaction Assesses perceived quality of care Continuous monitoring Staff compliance rates Measures adherence to protocols Periodic audits Organizational Problem Medication errors at MGH occur at an estimated rate of 40 per 1,000 patient days, representing a substantial patient safety risk. Contributing factors include high patient volumes, increasing clinical complexity due to comorbidities, and workforce shortages. These conditions elevate cognitive load, increase fatigue, and reduce adherence to standardized protocols (Tariq et al., 2024). Impact Area Consequences Patient outcomes Adverse drug events, prolonged hospitalization Financial costs Increased treatment expenses Organizational reputation Reduced patient trust Staff well-being Burnout, stress, reduced job satisfaction Preventable medication-related harm continues to be a major contributor to mortality in healthcare systems, underscoring the urgency of systemic interventions (Tariq et al., 2024). Comprehensive Quality and Safety Plan Enhancing Medication Safety with BCMA Barcode Medication Administration (BCMA) systems are proposed to improve medication verification processes. Integration of EHRs with Decision-Support Tools Electronic Health Records (EHRs) integrated with clinical decision-support systems enhance real-time clinical decision-making. Requirement Description Staff training Ensures proper system use Workflow integration Aligns digital tools with clinical processes Data accessibility Enables real-time decision-making Standardized Handoff Communication Protocols Structured communication frameworks such as SBAR improve information accuracy during care transitions. Existing Organizational Functions, Processes, and Behaviors Several internal dynamics contribute to medication errors at MGH. Factor Effect High patient volume Increased workload and fatigue Staffing shortages Reduced attention to detail Poor communication Misinterpretation of medication orders Lack of EHR integration Limited access to safety alerts Current Outcome Measures To evaluate progress, MGH utilizes key performance indicators: Indicator Description Strengths Limitations Medication Error Rate Errors per 1,000 patient days Quantifiable and objective May overlook near misses Patient Satisfaction Patient perception of care Reflects experience Subjective variability Staff Adherence Compliance with protocols Measures procedural consistency Limited contextual insight Actionable Plan to Achieve Improved Outcomes Strategy Key Actions BCMA Implementation Policy enforcement, staff training, compliance audits, system updates EHR Integration Decision-support adoption, error alert systems, data security enhancement SBAR Communication Standardized handoffs, simulation training, documentation and feedback These interventions collectively target system-level vulnerabilities and human factors contributing to medication errors. Assumptions of the Plan Failure in any of these areas may limit the effectiveness of interventions. Future Vision and Nurse Leaders’ Role MGH aims to establish a patient-centered environment where safety is embedded into every clinical process. NURS FPX 6212 Assessment 4 Planning for Change: A Leader’s Vision Leadership Role Contribution Change management Drives implementation of safety initiatives Team coordination Promotes interdisciplinary collaboration Quality improvement Monitors outcomes and ensures compliance Advocacy Supports patient safety policies Nurse leaders play a pivotal role in fostering accountability, encouraging reporting, and sustaining improvements (Nurmeksela et al., 2021). Conclusion Medication errors at MGH represent a complex and high-risk challenge affecting patients, staff, and organizational performance. Addressing this issue requires an integrated strategy combining advanced technologies such as BCMA and EHR systems, standardized communication protocols, and strong leadership. Nurse leaders are instrumental in operationalizing these changes and sustaining a culture of safety. Through coordinated efforts, MGH can significantly reduce medication errors, improve patient outcomes, and strengthen healthcare quality. References Berdot, S., Vilfaillot, A., Bezie, Y., Perrin, G., Berge, M., Corny, J., Thi, T. T. P., Depoisson, M., Guihaire, C., Valin, N., Decelle, C., Karras, A., Durieux, P., Lê, L. M. M., & Sabatier, B. (2021). Effectiveness of a “do not interrupt” vest intervention to reduce medication errors during medication administration: A multicenter cluster randomized controlled trial. BMC Nursing, 20(1), 1–11. https://doi.org/10.1186/s12912-021-00671-7 NURS FPX 6212 Assessment 4 Planning for Change: A Leader’s Vision Bindra, A., Sameera, V., & Rath, G. (2021). Human errors and their prevention in healthcare. Journal of Anaesthesiology Clinical Pharmacology, 37(3), 328. https://doi.org/10.4103/joacp.joacp_364_19 Lee, J. Y., McFadden, K. L., Lee, M. K., & Gowen, C. R. (2021). U.S. hospital culture profiles for better performance in patient safety, patient satisfaction, Six Sigma, and lean implementation. International Journal of Production Economics, 234, 108047. https://doi.org/10.1016/j.ijpe.2021.108047 Lou, S. S., Lew, D., Harford, D., Lu, C., Evanoff, B., Duncan, J. G., & Kannampallil, T. (2022). Temporal associations between EHR-derived workload, burnout, and errors: A prospective cohort study. Journal of General Internal Medicine, 37(9), 2165–2172. https://doi.org/10.1007/s11606-022-07620-3 NURS FPX 6212 Assessment 4 Planning for Change: A Leader’s Vision Nurmeksela, A., Mikkonen, S., Kinnunen, J., & Kvist, T. (2021). Relationships between nurse managers’ work activities, nurses’ job satisfaction, patient satisfaction, and medication errors at the unit level: A correlational study. BMC Health Services Research, 21(1), 296. https://doi.org/10.1186/s12913-021-06288-5 Tariq, R., Scherbak, Y., Vashisht, R., & Sinha, A. (2024). Medication dispensing errors and prevention. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519065/
NURS FPX 6212 Assessment 3 Outcome Measures, Issues, and Opportunities
Student Name Capella University NURS-FPX 6212 Health Care Quality and Safety Management Prof. Name Date Outcome Measures, Issues, and Opportunities Medication errors (MEs) represent a persistent patient safety challenge at Mercy General Hospital (MGH), as identified through a recent organizational gap analysis. These errors are not isolated incidents; rather, they emerge from systemic issues embedded within workflows, structural design, and operational processes. A comprehensive evaluation of these contributing factors is essential for understanding their downstream impact on patient outcomes and for designing targeted interventions. To improve care delivery, MGH must rely on clearly defined quality and safety metrics that enable performance tracking and accountability. When these metrics are aligned with a structured change framework, the organization can enhance information exchange, reduce clinical variability, and ultimately improve patient outcomes. Establishing a culture that prioritizes safety and continuous learning is equally critical for sustaining long-term improvements. Analysis of High-Performing Organizations How do high-performing healthcare organizations reduce medication errors? High-performing healthcare organizations minimize medication errors by embedding safety into their operational systems and clinical culture. They emphasize standardized processes, evidence-based practices, and continuous performance monitoring. These institutions also prioritize interdisciplinary collaboration and maintain robust communication channels to reduce variability in care delivery. The following organizational functions are central to reducing medication errors: Organizational Functions Description Communication Structured, consistent communication across care teams reduces ambiguity and prevents errors. Personnel Training Continuous professional development ensures adherence to clinical protocols and competency in medication management. Interdisciplinary Coordination Collaboration among nurses, physicians, and pharmacists enhances decision-making accuracy. Data Management Reliable data systems support monitoring of medication use and identification of adverse events. In addition, specific interventions—such as barcode medication administration (BCMA), medication checklists, and standardized reconciliation processes—have demonstrated measurable reductions in medication errors and improvements in workflow efficiency (Grailey et al., 2023). Equally important is the establishment of a non-punitive reporting culture. When healthcare professionals are encouraged to report errors without fear of blame, organizations gain access to critical data that supports system-wide improvements. Leadership plays a decisive role in reinforcing accountability, facilitating knowledge sharing, and embedding safety practices into daily routines. What gaps remain in research regarding staff compliance and patient outcomes? Although procedural improvements have been widely implemented, gaps remain in understanding how staff compliance directly influences patient outcomes. Several areas require further empirical investigation: Addressing these gaps will require stronger data governance, improved measurement tools, and collaboration among stakeholders to ensure that quality improvement strategies are both evidence-based and contextually relevant. Organizational Support for Outcome Measures What organizational factors influence medication errors at MGH? Medication safety outcomes at MGH are shaped by multiple organizational determinants, including leadership effectiveness, communication systems, and technological infrastructure. Key performance indicators (KPIs) such as medication error rates, patient satisfaction, and compliance with safety protocols provide measurable insights into organizational performance. The following table outlines critical factors and their roles in reducing medication errors: Factor Role in Reducing Medication Errors Leadership Promotes a culture of safety and accountability across all levels of the organization. Interdisciplinary Communication Enables timely and accurate exchange of clinical information. Reporting Systems Supports early detection, documentation, and resolution of errors. Technology (BCMA & EHR) Minimizes human error and ensures accurate medication administration. Staff Engagement Strengthens adherence to protocols and improves patient-centered care. Evidence indicates that strong leadership engagement enhances teamwork, improves staff competency, and contributes to better patient outcomes (Nurmeksela et al., 2021). Furthermore, integrating technologies such as BCMA and electronic health records (EHRs) supports safe medication practices by automating verification processes and standardizing care transitions (Grailey et al., 2023). Human factors—including staff accountability and engagement—remain equally important. A supportive environment that encourages reporting and continuous improvement is essential for sustaining gains in patient safety (Elliott et al., 2021). Quality and Safety Outcomes and Proposed Measures What are MGH’s current performance metrics, and what improvements are targeted? MGH has identified specific performance benchmarks to evaluate progress in medication safety and patient experience. Outcome Measure Current Value Target Medication Errors 40 per 1,000 patient days 20 per 1,000 patient days Patient Satisfaction 80% 90% Compliance with Medication Safety Protocols 60% 80% To achieve these targets, MGH plans to implement several evidence-based interventions: Sustained improvement will depend on continuous staff training, routine audits, and reliable data collection systems. Tools such as performance dashboards, patient surveys, and staff feedback mechanisms will support ongoing monitoring. Standardizing reporting processes is particularly important to ensure the accuracy and consistency of performance data. Performance Issues and Opportunities in the Healthcare Setting What factors contribute to performance issues at MGH? Several systemic and operational challenges contribute to medication errors at MGH: These factors collectively increase the likelihood of dosing inaccuracies and reduce the time available for safe medication administration. How can MGH improve medication process accuracy? MGH can enhance medication safety by implementing targeted operational strategies: Strategy Expected Outcome Optimize Staffing & Task Organization Reduces workload burden and improves care quality Integrate BCMA & EHR Systems Enhances accuracy and reduces variability in medication processes Standardize Communication Protocols Improves handoff efficiency and minimizes miscommunication Strengthen Training Programs Addresses competency gaps and reinforces adherence to protocols Future research should focus on identifying root causes of medication errors in high-demand clinical settings, evaluating the impact of staffing levels, assessing training effectiveness, and exploring the role of patient engagement in medication safety. Change Model for Outcome Measurement and Knowledge Sharing How can MGH systematically reduce medication errors? The Plan-Do-Study-Act (PDSA) model offers a structured, iterative approach to quality improvement and error reduction (Chen et al., 2020). Phase Actions at MGH Plan Define targets for reducing medication errors, improving patient satisfaction, and increasing compliance; assess operational needs. Do Implement pilot interventions such as BCMA, EHR integration, SBAR communication, and staff training in selected units. Study Evaluate outcomes using error rates, satisfaction scores, and compliance data; gather feedback from staff and patients. Act Refine processes based on findings and scale successful interventions across the organization. Knowledge dissemination is achieved through structured training programs, workshops, and clear communication channels. Continuous feedback loops and interdisciplinary collaboration ensure that improvements are informed
NURS FPX 6212 Assessment 2 Executive Summary
Student Name Capella University NURS-FPX 6212 Health Care Quality and Safety Management Prof. Name Date Executive Summary Inpatient falls continue to pose a serious patient safety challenge at Methodist University Hospital (MUH), often stemming from insufficient preventive protocols and inconsistent patient monitoring. Addressing this issue requires systematic evaluation of outcome indicators and the application of evidence-based interventions. This summary outlines the importance of measuring fall-related outcomes, identifies key performance indicators, and clarifies the leadership responsibilities necessary to drive measurable improvements in patient safety and care quality. Quality and Safety Outcome Measures Why are outcome measures essential for reducing inpatient falls? Outcome measures provide objective data that allow healthcare organizations to evaluate the effectiveness of fall prevention strategies and identify areas requiring improvement. At MUH, these metrics support reductions in fall frequency, injury severity, readmissions, and associated financial costs. Core indicators include fall rates, incidence of fall-related injuries, patient satisfaction levels, and cost implications. Key Outcome Measures Explained Fall Rates Fall rates quantify the number of patient falls per 1,000 patient days within a specific timeframe (AHRQ, 2024). These rates are instrumental in identifying trends and evaluating intervention outcomes. Fall-Related Injuries This measure evaluates the extent of harm resulting from falls, offering insight into the effectiveness of safety protocols (AHRQ, 2024). Research indicates that structured interventions have reduced injury occurrences significantly (Dykes et al., 2023). Patient Satisfaction Patient satisfaction reflects how individuals perceive safety measures and fall prevention efforts. MUH currently reports a 65% satisfaction rate in this domain. Cost of Falls This metric assesses the financial burden associated with inpatient falls and the economic benefits of prevention programs. Evidence suggests substantial cost savings when preventive strategies are implemented (Dykes et al., 2023). NURS FPX 6212 Assessment 2 Executive Summary Table 1. Outcome Measures for Inpatient Falls at MUH Outcome Measure Description Strengths Limitations Fall Rates Falls per 1,000 patient days Identifies trends; evaluates interventions Requires accurate reporting; lacks severity context Fall-Related Injuries Injuries resulting from patient falls Measures direct patient harm Does not include near-misses or emotional effects Patient Satisfaction Patient perception of safety efforts Provides experiential feedback Subjective and variable Cost of Falls Financial impact of falls and prevention efforts Highlights economic value of prevention Excludes indirect and reputational costs Strategic Value of Outcome Measures How do these measures support hospital strategy? Outcome metrics play a central role in informing MUH’s strategic planning and operational improvements: Integrating these indicators into a structured performance management system ensures alignment with organizational goals and continuous quality improvement. Relationship Between Inpatient Falls and Outcome Measures How do inpatient falls impact overall hospital performance? Inpatient falls represent systemic failures that influence both patient outcomes and organizational efficiency. Elevated fall rates often signal deficiencies in safety practices, leading to increased injury rates, prolonged hospital stays, and higher treatment costs. Financial analyses indicate that both injurious and non-injurious falls contribute significantly to healthcare expenditures, with costs exceeding $35,000 per 1,000 patient days (Dykes et al., 2023). Environmental hazards—such as slippery floors and unsafe equipment—also contribute to fall incidents (Janse et al., 2020). Comprehensive data collection, including timing, location, staffing levels, and patient behavior, is essential for designing targeted and effective prevention strategies. Outcome Measures and Strategic Initiatives What strategies can reduce inpatient falls at MUH? MUH employs several evidence-based interventions aligned with outcome metrics: Table 2. Target Performance Goals for MUH Metric Current Status Target Goal Justification Fall Rate Baseline ↓ 60% Reduce injury incidence and enhance patient safety Patient Satisfaction 65% 95% Improve patient trust and engagement Cost Savings Baseline ↑ 85% Minimize financial burden of fall-related events Monitoring these targets enables MUH to evaluate progress, refine interventions, and sustain improvements in patient safety. Leadership Role What role do nurse leaders play in fall prevention? Nurse leaders are central to the successful implementation of fall prevention strategies. Their responsibilities include fostering a culture of safety, ensuring resource availability, and promoting adherence to clinical protocols. Key leadership actions include: Creating a non-punitive reporting environment is particularly critical, as it promotes learning and continuous improvement (Gaur et al., 2021). Effective leadership directly influences staff engagement, accountability, and patient outcomes (Murray & Cope, 2021). Conclusion Reducing inpatient falls at MUH requires a structured, data-driven approach that integrates outcome measurement, targeted interventions, and strong leadership. Continuous monitoring of fall rates, injury data, patient satisfaction, and cost implications enables informed decision-making and sustained quality improvement. Through leadership engagement and interdisciplinary collaboration, MUH can strengthen its safety culture, reduce fall incidents, and enhance overall patient care outcomes. References AHRQ. (2024). How do you measure fall rates and fall prevention practices? Agency for Healthcare Research and Quality. https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/measure-fall-rates.html Albertini, A. C. D. S., & Peduzzi, M. (2024). Interprofessional approach to fall prevention in hospital care. Revista da Escola de Enfermagem da USP, 58, e20230239. https://doi.org/10.1590/1980-220x-reeusp-2023-0239en NURS FPX 6212 Assessment 2 Executive Summary Bernet, N. S., Everink, I. H., Schols, J. M. G. A., Halfens, R. J. G., Richter, D., & Hahn, S. (2022). Hospital performance comparison of inpatient fall rates: The impact of risk adjustment. BMC Health Services Research, 22(1). https://doi.org/10.1186/s12913-022-07638-7 DiGerolamo, K. A., & Chen-Lim, M. L. (2020). Educational interventions to improve staff collaboration in fall prevention. Journal of Pediatric Nursing, 57, 43–49. https://doi.org/10.1016/j.pedn.2020.10.027 Dykes, P. C., Bowen, M., Lipsitz, S., Franz, C., Adelman, J., Adkison, L., & Bates, D. W. (2023). Cost-benefit analysis of fall prevention programs. JAMA Health Forum, 4(1), e225125. https://doi.org/10.1001/jamahealthforum.2022.5125 NURS FPX 6212 Assessment 2 Executive Summary Gaur, S., Kumar, R., Gillespie, S. M., & Jump, R. L. P. (2021). Safety culture in healthcare organizations. Journal of the American Medical Directors Association, 23(2), 241–246. https://doi.org/10.1016/j.jamda.2021.12.017 Janse, R., Anita, & Crowley, T. (2020). Factors contributing to patient falls in hospital settings. Health SA Gesondheid, 25, 1392. https://doi.org/10.4102/hsag.v25i0.1392 Murray, M., & Cope, V. (2021). Leadership and patient safety outcomes. Collegian, 28(6), 604–609. https://doi.org/10.1016/j.colegn.2021.07.004
NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis
Student Name Capella University NURS-FPX 6212 Health Care Quality and Safety Management Prof. Name Date Quality and Safety Gap Analysis Patient falls within hospital environments represent a persistent challenge affecting both patient safety and care quality. These incidents are associated with a wide range of negative outcomes, including physical injuries, emotional distress, prolonged hospitalization, and increased financial burden on healthcare systems. This gap analysis examines Methodist University Hospital (MUH) to determine the underlying causes of inpatient falls and to propose evidence-based strategies aimed at improving patient safety and healthcare quality outcomes. Organizational Problems and Adverse Quality and Safety Outcomes What is the primary patient safety concern at MUH? The most critical safety issue identified at MUH is the occurrence of inpatient falls. These events can lead to serious consequences such as fractures, head injuries, hemorrhage, and, in extreme cases, mortality. In addition to physical harm, patients often experience psychological effects, including fear and anxiety, which may reduce their confidence in the care provided and overall satisfaction levels. From a financial perspective, falls contribute to increased treatment costs and may result in penalties from regulatory bodies, thereby placing additional strain on hospital resources (Ghosh et al., 2022; Turner et al., 2020). Data reported by the Centers for Medicare and Medicaid Services (CMS) indicate that MUH has a fall rate of 0.295 per 1,000 admissions, which is below established safety thresholds (Leapfrog, 2024). However, national statistics reveal a broader concern, with fall rates ranging from 1.7 to 16.9 per 1,000 admissions. Among these cases, moderate injuries occur in 6.9%–72.2% of incidents, while severe injuries account for 0.8%–30.1% (Ghosh et al., 2022). Furthermore, approximately 6%–27% of inpatient falls in the United States lead to significant harm, with average costs reaching $4,200 per incident. What factors contribute to patient falls? Patient falls are multifactorial, arising from a combination of intrinsic and extrinsic influences. These contributing factors can be categorized as follows: Factor Category Description Patient-related Advanced age, limited mobility, cognitive impairment, and medication side effects Environmental Poor lighting, slippery surfaces, cluttered spaces, and limited accessibility Organizational Inadequate staffing levels and inconsistent adherence to safety protocols Technological Absence of effective monitoring systems and insufficient use of fall detection devices Failure to adequately address these factors can lead to longer hospital stays, increased operational costs, reputational damage, and potential reductions in CMS reimbursements (Turner et al., 2020). Additionally, gaps remain in understanding the effectiveness of current prevention strategies and the integration of emerging technologies at MUH. Practice Changes What practice changes can reduce patient falls at MUH? An internal evaluation at MUH identified inconsistencies in fall risk assessment and insufficient preventive measures as major contributors to fall incidents. To address these issues, the following evidence-based interventions are recommended: These strategies collectively aim to minimize fall occurrences while strengthening patient safety and care delivery standards. Prioritization of the Proposed Change Strategies Priority Level Strategy Justification 1 Staff training Enhances rapid identification of risks and appropriate intervention (Saki et al., 2023) 2 Standardized risk assessment Ensures consistent identification of high-risk patients (Strini et al., 2021) 3 Interdisciplinary teams Promotes collaborative decision-making and improved outcomes (Albertini & Peduzzi, 2024) 4 Environmental modifications Supports safety but depends on effective human oversight (Turner et al., 2020) Staff training is ranked highest due to its direct influence on clinical decision-making and patient monitoring. While environmental improvements are important, they are less effective without competent staff engagement. Quality and Safety Culture and Its Evaluation How will the proposed changes enhance safety culture at MUH? The implementation of these interventions is expected to strengthen MUH’s safety culture by promoting accountability, collaboration, and proactive risk management. Key mechanisms include: Evaluation Metrics Metric Purpose Patient fall rate Measures effectiveness of interventions Staff compliance Assesses adherence to safety protocols Satisfaction surveys Evaluates perceptions of safety and care quality Audit results Identifies improvement areas and ensures sustainability Organizational Culture Affecting Quality and Safety Outcomes Organizational culture plays a pivotal role in determining patient safety outcomes. Hierarchical structures in healthcare settings may discourage open communication, leading to underreporting of falls due to fear of blame or disciplinary action. In contrast, a supportive and transparent culture fosters: Such environments contribute to reduced fall rates and improved overall care quality (Alabdullah & Karwowski, 2024). Conversely, organizations that prioritize financial performance over patient safety risk compromising transparency and increasing adverse events. Justification of Necessary Changes in an Organization To effectively reduce inpatient falls, MUH must adopt a comprehensive and integrated strategy that includes: These measures address existing gaps in practice, improve staff competency, and enhance patient safety outcomes. Conclusion This analysis highlights the necessity for systematic improvements at MUH to address inpatient falls. Falls not only compromise patient safety but also increase healthcare costs and negatively affect care quality. The adoption of evidence-based interventions—such as staff education, standardized assessments, environmental enhancements, and interdisciplinary collaboration—can significantly reduce fall risks. Ultimately, these changes contribute to a stronger safety culture and improved healthcare delivery. References Alabdullah, H., & Karwowski, W. (2024). Patient safety culture in hospital settings across continents: A systematic review. Applied Sciences, 14(18), 8496. https://doi.org/10.3390/app14188496 Albertini, A. C. D. S., & Peduzzi, M. (2024). Interprofessional approach to fall prevention in hospital care. Revista da Escola de Enfermagem da USP, 58, e20230239. https://doi.org/10.1590/1980-220x-reeusp-2023-0239en NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis Ghosh, M., O’Connell, B., Yamoah, E. A., Kitchen, S., & Coventry, L. (2022). A retrospective cohort study of factors associated with severity of falls in hospital patients. Scientific Reports, 12(1), 12266. https://doi.org/10.1038/s41598-022-16403-z Leapfrog. (2024). Methodist University Hospital. Leapfrog Hospital Safety Grade. https://www.hospitalsafetygrade.org/table-details/methodist-university-hospital Saki, M., Ariaienezhad, B., Ebrahimzadeh, F., Almasian, M., & Heydari, H. (2023). The effect of nurses’ training on the implementation of preventive measures for falls in hospitalized elderly patients. International Archives of Health Sciences, 10(4), 144–149. https://doi.org/10.48307/iahsj.2023.183008 Strini, V., Schiavolin, R., & Prendin, A. (2021). Fall risk assessment scales: A systematic literature review. Nursing Reports, 11(2), 430–443. https://doi.org/10.3390/nursrep11020041 NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis Turner, K., Staggs, V. S., Potter, C., Cramer, E., Shorr, R. I., & Mion, L. C. (2020). Fall prevention practices and implementation